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PN HESI Med Surg V2/ Latest 2022/ 55 Questions & Answers

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1. A primigravid client at 26 weeks' gestation asks the nurse what causes heartburn during pregnancy. The nurse should explain to the client that heartburn during pregnancy is usually caused by whic... h of the following? 1. Increased peristaltic action during pregnancy. 2. Displacement of the stomach by the diaphragm. 3. Decreased secretion of hydrochloric acid. 4. Backflow of stomach contents into the esophagus. (Ans- 4. Backflow of stomach contents into the esophagus. 2. A client at a follow-up appointment after having a miscarriage 2 weeks previously yells at the nurse, "How could God do this to me? I've never done anything wrong." Which of the following responses by the nurse would be most appropriate at this time? 1. "God can handle your anger. It's okay." 2. "I know you are angry. It's so hard to lose your baby." 3. "It isn't God's fault. It was an accident." 4. "You're a strong person. You will get through this." (Ans- 2. "I know you are angry. It's so hard to lose your baby." 3. A client who has been prescribed chemotherapy is worried and wants to take herbal treatments instead. The nurse's best response to the client is which of the following? 1. "You are making a mistake and placing your life in jeopardy." 2. "Herbal treatments are not approved by the government's regulatory agency." 3. "Herbal treatments have not been researched with cancer." 4. "Tell me about your concerns with chemotherapy." (Ans- 4. "Tell me about your concerns with chemotherapy." 4. A 4-year-old child is admitted for a cardiac catheterization. Which of the following is most important to include as the nurse teaches this child about the cardiac catheterization? 1. A plastic model of the heart. 2. A catheter that will be inserted into the artery. 3. The parents. 4. Other children undergoing a catheterization. (Ans- 3. The parents. 5. A client has a reddened area over a bony prominence. The nurse finds a nursing assistant massaging this area. The nurse should: 1. Reinforce the nursing assistant's use of this intervention over the bony prominence. 2. Explain to the nursing assistant that massage is effective because it improves blood flow to the area. 3. Inform the nursing assistant that massage is even more effective when combined with the use of lotion. 4. Instruct the nursing assistant that massage is contraindicated because it decreases blood flow to the area. (Ans- 4. Instruct the nursing assistant that massage is contraindicated because it decreases blood flow to the area. 6. A worried mother confides in the nurse that she wants to change primary care providers because her infant is not getting better. The best response by the nurse is which of the following? 1. "This doctor has been on our staff for 20 years." 2. "I know you are worried, but the doctor has an excellent reputation." 3. "You always have an option to change. Tell me about your concerns." 4. "I take my own children to this doctor." (Ans- 3. "You always have an option to change. Tell me about your concerns." 7. A mother who is breast-feeding and has known food sensitivities is asking the nurse what foods she should avoid in her diet. The nurse should advise her to avoid which foods? Select all that apply. 1. Shellfish. 2. Eggs. 3. Peanuts. 4. Beef. 5. Lamb . (Ans- 1. Shellfish. 2. Eggs. 3. Peanuts. 8. A widowed client who is receiving chemotherapy tells the nurse that he does not like to cook for himself. A community resource for this client is: 1. Hospice/palliative care association. 2. Home care/visiting nurses group. 3. Meals on Wheels. 4. Association for Retirees. (Ans- 3. Meals on Wheels. 9. After the client has a temporary pacemaker inserted, the nurse should verify that which of the following has been documented? 1. The client's cardiovascular status. 2. The client's emotional state. 3. The type of sedation used. 4. Pacemaker rate, type, and settings. (Ans- 1. The client's cardiovascular status. 10. The nurse judges that the parent of a 9-month-old infant in a hip spica cast understands how to feed the child when the parent states which of the following? 1. "I can lay my child flat and feed that way." 2. "I'll raise my child's head up and leave the hips and legs on a pillow." 3. "I can borrow a special feeding table to use." 4. "It will take two of us, one to hold and one to feed." (Ans- 3. "I can borrow a special feeding table to use." 11. The nurse is assessing home care needs for a group of clients. Which clients qualify for home care services? The client who: (Select all that apply.) 1. Requires monitoring of prothrombin time due to Coumadin (warfarin) therapy. 2. Needs additional instruction regarding preparation of food on a low-sodium diet. 3. Has episodes of vertigo that result in falls. 4. Has multiple sclerosis with an open, draining lesion on a foot. 5. Needs stronger lenses for glasses. (Ans- 3. Has episodes of vertigo that result in falls. 4. Has multiple sclerosis with an open, draining lesion on a foot. 12. Forty-eight hours after a ventriculoperitoneal shunt placement, an infant is irritable and vomits a large amount. The assessment reveals a bulging fontanel. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary health care provider with the recommendation for: 1. A dose of morphine (Astramorph). 2. A fluid bolus of normal saline. 3. A computerized tomography scan. 4. A dose of furosemide (Lasix). (Ans- 3. A computerized tomography scan. 13. The nursing staff has finished restraining a client. In addition to determining whether anyone was injured, the staff is mandated to evaluate the incident to obtain which of the following ultimate outcomes? 1. Coordinate documentation of the incident. 2. Resolve negative feelings and attitudes. 3. Improve the use of restraint procedures. 4. Calm down before returning to the other clients. (Ans- 3. Improve the use of restraint procedures. 14. The nurse is caring for a client who has experienced severe multiple trauma. The client's arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. This finding is an indicator of the development of which of the following conditions? 1. Hospital-acquired pneumonia. 2. Hypovolemic shock. 3. Acute respiratory distress syndrome (ARDS). 4. Asthma. (Ans- 3. Acute respiratory distress syndrome (ARDS) 15. A client asks the nurse why it is necessary to complete an advance directive on admission to the hospital. The nurse's best response is which of the following? 1. "This will provide a substitute for informed discussion with your primary care provider." 2. "It is your chance to make your wishes known if you ever become incapable of making your own decisions." 3. "Your primary care provider will make the best decisions for you in an emergency." 4. "Are you worried that extraordinary means will be taken if you are dying?" (Ans- 2. "It is your chance to make your wishes known if you ever become incapable of making your own decisions." [Show More]

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